Vision loss and vascular compromise with facial and periocular injections

Abstract

Facial and periorbital regions are rich in vascular supply given the extensive internal-external carotid branching and anastomoses.1Tansatit T. Moon H.J. Apinuntrum P. Phetudom T. Verification of embolic channel causing blindness following filler injection.Aesthetic Plast Surg. 2015; 39: 154-161Crossref PubMed Scopus (35) Google Scholar As a result, any foreign material introduced (either accidentally or iatrogenically) around the eye and facial region has the potential of introducing emboli into the ophthalmic circulation, which could lead to devastating consequences. Severe and often permanent vision loss after injections in the facial areas is a rare, but known complication that has been reported within nasolabial folds, glabella, intranasal, periocular, and forehead regions.2Park S.H. Sun H.J. Choi K.S. Sudden unilateral visual loss after autologous fat injection into the nasolabial fold.Clin Ophthalmol. 2008; 2: 679-683PubMed Google Scholar, 3Lee C.M. Hong I.H. Park S.P. Ophthalmic artery obstruction and cerebral infarction following periocular injection of autologous fat.Korean J Ophthalmol. 2011; 25: 358-361Crossref PubMed Scopus (46) Google Scholar, 4Dreizen N.G. Framm L. Sudden unilateral visual loss after autologous fat injection into the glabellararea.Am J Ophthalmol. 1989; 107: 85-87Abstract Full Text PDF PubMed Scopus (139) Google Scholar, 5Carle M.V. Roe R. Novack R. et al.Cosmetic facial fillers and severe vision loss.JAMA Ophthalmol. 2014; 132: 637-639Crossref PubMed Scopus (4) Google Scholar, 6Carle M.V. Roe R. Novack R. Boyer D.S. Cosmetic facial fillers and severe vision loss.JAMA Ophthalmol. 2014; 132: 637-639Crossref PubMed Scopus (77) Google Scholar, 7Carruthers J.D. Fagien S. Rohrich R.J. Weinkle S. Carruthers A. Blindness caused by cosmetic filler injection: a review of cause and therapy.Plast Reconstr Surg. 2014; 134: 1197-1201Crossref PubMed Scopus (178) Google Scholar, 8Park S.W. Woo S.J. Park K.H. et al.Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections.Am J Ophthalmol. 2012; 154: 653-662Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar We review the current literature on the topic of visual and vascular compromise caused by facial and periorbital injections, as well as present a case of transient vision loss to no light perception (NLP) after subtenon triamcinolone acetonide (Kenalog; Bristol-Myers Squibb) injection because of ophthalmic artery occlusion (OAO) with full visual recovery.A 77-year-old female with persistent bilateral cystoid macular edema (CME) after cataract surgery refractory to topical corticosteroid and nonsteroidal anti-inflammatory drug was referred for subtenon Kenalog injection. The patient received 2 uneventful subtenon Kenalog injections bilaterally because of the persistent CME.On her third visit for subtenon Kenalog injection, 15 seconds after injection of the right eye over the superotemporal quadrant, the patient suffered vision loss from 20/80 to NLP with associated nausea and right orbital pain. Immediate anterior segment examination was unremarkable other than localized tenderness and fullness over the lacrimal gland (Fig. 1A). Posterior segment examination demonstrated deep white lesions within the choroidal vasculature, as well as white crystal-like lesions within small terminal retinal arterioles (Fig. 2). There were no signs of central retinal artery occlusion (CRAO), but retinal perfusion was occludable with moderate digital pressure. Intravenous Fluorescein Angiography (IVFA) demonstrated small peripheral ischemic areas, but there was no filling defect. Urgent magnetic resonance scan of the orbits performed 2 hours after injection showed enlargement of the right medial rectus muscle and the lacrimal gland, without other orbital abnormalities (Fig. 1B).Fig. 2Fundus photograph after subtenon Kenalog injection with complete vision loss. Visible white crystal-like lesion of likely Kenalog suspension in the choroidal and retinal vasculature of right eye.View Large Image Figure ViewerDownload (PPT)Repeat examination after the magnetic resonance imaging, approximately 4 hours later, showed the patient had experienced a steady vision improvement after injection back to the 20/80 level. At 1-week follow-up, vision improved to 20/50 with dramatic resolution of her CME on optical coherence tomography. Fundus examination demonstrated complete resolution of the white crystal-like lesions within the retinal arteries and choroidal vasculature. At 1-month follow-up, patient’s best corrected visual acuity improved to 20/40 without any residual signs of CME.Posterior subtenon injection of corticosteroid was first described by Nozik in 1972 for the treatment of uveitis.9Nozik R.A. Periocular injection of steroids.Trans Am Acad Ophthalmol Otolaryngol. 1972; 76: 695-795PubMed Google Scholar Since then, subtenon Kenalog injection has been used extensively among ophthalmologists as an effective method for controlling uveitis refractory to topical medications. Although subtenon injection of Kenalog has been generally considered safe, numerous complications have been reported, such as soft tissue swelling, cataract formation, increased intraocular pressure, pseudoptosis, accidental injection into the subretinal space and globe penetration, retrobulbar hemorrhage, and retinal and choroidal vascular occlusion.10Modarres M. Parvaresh M.M. Peyman G.A. Accidental subretinal injection of triamcinolone acetonide.Ophthalmic Surg Lasers. 1998; 29: 935-938PubMed Google Scholar, 11Moshfeghi D.M. Lowder C.Y. Roth D.B. Kaiser P.K. Retinal and choroidal vascular occlusion after posterior sub-Tenon triamcinolone injection.Am J Ophthalmol. 2002; 134: 132-134Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 12Doshi A. Gariano R.F. Visual loss associated with accidental subretinal injection of triamcinolone acetonide.Retin Cases Brief Rep. 2008; 2: 160-162Crossref PubMed Google Scholar Among these, vascular occlusion is considered the most serious and has been associated with permanent and irreversible visual loss.In our case, we propose that the vision loss was due to vascular compromise from Kenalog being accidentally injected into the lacrimal artery and travelling retrogradely into the ophthalmic artery, resulting in transient OAO. The enlargement seen in the lateral rectus muscle and lacrimal gland was likely due to local accumulation of Kenalog and vascular congestion of the lacrimal artery. Luckily, there was no permanent vision loss as the OAO from Kenalog suspension was transient. The Kenalog preparation is made of a suspension free of large particles/emboli that could result in permanent or prolonged occlusion. After the injection pressure dissipates, the Kenalog suspension could disperse and flow into distal smaller vessels under the arterial pressure, thereby relieving and recanalizing the transient vascular obstruction but travelling to more distal branches of the ophthalmic artery, resulting in clinically visible deposits within the choroid via the short posterior ciliary arteries and the retina through the central retinal artery. As the blood flow is re-established within the ophthalmic artery and central retina artery, the vision recovered spontaneously and the CME resolved quickly with the high concentration of intravascular Kenalog.To our knowledge, this is the first case in the literature of transient OAO with full and spontaneous visual recovery. Also, it is important to note that the manufacturer has specifically recommended against the use of intraturbinal, periocular, and intraocular Kenalog injections because of the lack of safety studies and risk for blindness.13KENALOG®-10 (triamcinolone acetonide) prescribing information. Princeton, NJ: Bristol-Myers Squibb Company. Available from: packageinserts.bms.com/pi/pi_kenalog-10.pdfGoogle Scholar Indeed, vision loss caused by vascular compromise after intranasal, forehead, and eyelid Kenalog injection has been well documented in the literature.14Moss W.J. Kjos K.B. Karnezis T.T. Lebovits M.J. Intranasal steroid injections and blindness: our personal experience and a review of the past 60 years.Laryngoscope. 2015; 125: 796-800Crossref PubMed Scopus (17) Google Scholar, 15Edwards A.O. Central retinal artery occlusion following forehead injection with a corticosteroid suspension.Pediatr Dermatol. 2008; 25: 460-461Crossref PubMed Scopus (18) Google Scholar, 16Liu O.G. Chunming L. Juanjuan W. Xiaoyan X. Central retinal artery occlusion and cerebral infarction following forehead injection with a corticosteroid suspension for vitiligo.Indian J Dermatol Venereol Leprol. 2014; 80: 177-179Crossref PubMed Scopus (16) Google Scholar, 17Yağci A. Palamar M. Eğrilmez S. Sahbazov C. Ozbek S.S. Anterior segment ischemia and retinochoroidal vascular occlusion after intralesional steroid injection.Ophthal Plast Reconstr Surg. 2008; 24: 55-57Crossref PubMed Scopus (23) Google Scholar, 18Martin P.A. Church C.A. Petti Jr, G.H. Hedayi R. Visual loss after intraturbinate steroid injection.Otolaryngol Head Neck Surg. 2003; 128: 280-281Crossref PubMed Scopus (11) Google Scholar Therefore, it is critical for physicians to document and have thorough discussions about all the potential risks associated with facial and periocular injections as part of the informed consent process.In addition to periocular Kenalog injections, facial filler injections for cosmetic wrinkle removal and facial augmentation have also been reported to have severe visual-threatening complications secondary to vascular occlusion. It is important for ophthalmologists to be aware of the potential visual complications of facial filler injections because of their rising popularity for cosmetic purposes. Currently, facial filler injection is the second most commonly performed minor procedure by plastic surgeons and dermatologists after botulinum toxin injections.19American Society for Aesthetic Plastic Surgery. New York: ASAPS National Cosmetic Surgery Databank Statistics 2012. Available from: www.surgery.org/sites/default/files/ASAPS-2012-Stats.pdfGoogle Scholar, 20Ozturk C.N. Li Y. Tung R. et al.Complications following injection of soft-tissue fillers.Aesthet Surg J. 2013; 33: 862-877Crossref PubMed Scopus (161) Google ScholarVision loss presents as an immediate complication of facial filler injection with other associated signs and symptoms depending on the location of vascular occlusion.7Carruthers J.D. Fagien S. Rohrich R.J. Weinkle S. Carruthers A. Blindness caused by cosmetic filler injection: a review of cause and therapy.Plast Reconstr Surg. 2014; 134: 1197-1201Crossref PubMed Scopus (178) Google Scholar, 8Park S.W. Woo S.J. Park K.H. et al.Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections.Am J Ophthalmol. 2012; 154: 653-662Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar OAO, CRAO, and branch retinal artery occlusion (BRAO) after filler injections have all been reported. OAO and CRAO have been associated with the worst visual prognosis. Given the important vascular supply from branches of ophthalmic artery, OAO is commonly associated with pain, pupillary abnormalities, ophthalmoplegia, ptosis, decreased choroidal thickness, and absence of cherry red spot.8Park S.W. Woo S.J. Park K.H. et al.Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections.Am J Ophthalmol. 2012; 154: 653-662Abstract Full Text Full Text PDF PubMed Scopus (180) Google ScholarThe mechanism of vascular compromise from facial filler injections is thought to be due to retrograde injection of filler materials through distal arterioles under high injection pressure.7Carruthers J.D. Fagien S. Rohrich R.J. Weinkle S. Carruthers A. Blindness caused by cosmetic filler injection: a review of cause and therapy.Plast Reconstr Surg. 2014; 134: 1197-1201Crossref PubMed Scopus (178) Google Scholar, 8Park S.W. Woo S.J. Park K.H. et al.Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections.Am J Ophthalmol. 2012; 154: 653-662Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar Once the injection pressure has been removed, the filler materials travel distally and result in vascular occlusion depending on the filler particle size and the diameter of affected arteries. Many filler materials are available, differing by particle sizes and duration of effect. Fillers made of autologous fat, hyaluronic acid, collagen, and polymethyl methacrylate have been reported with visual complications. Of these, autologous fat and hyaluronic acid have been reported to account for the vast majority of filler-related vision loss reported in the literature, with autologous fat being responsible for approximately 50% of all cases. Autologous fat has also been established as the most likely filler material to cause OAO. The high risk associated with autologous fat and hyaluronic acid is likely due to their large particle size with hyaluronic acid particles measuring 400 μm in diameter and autologous fat composed of even larger and variable-sized fat globules.21Gold M.H. Use of hyaluronic acid fillers for the treatment of the aging face.Clin Interv Aging. 2007; 2: 369-376PubMed Google Scholar Given the 2-mm diameter of the ophthalmic artery and 160-μm diameter of the central retinal artery, it is understandable why autologous fat results in more OAO, whereas hyaluronic acid filler is more likely to result in CRAO.The site of facial filler injections is also a factor in the risk for visual complications with filler injections. Among all published reports, injections over glabella, nasolabial folds, and forehead regions are associated with the greatest risk. The risk for vascular compromise at each site is likely determined by the underlying vascular anastomoses and proximity to the ophthalmic artery. For instance, retrograde travel of emboli from the glabellar region likely comes from the supratrochlear or supraorbital artery, whereas dorsal nasal, angular, and/or lateral nasal arteries likely account for emboli travel of injections over the nasolabial folds.Contrasted with the complete visual recovery from transient OAO seen with Kenalog injection in the case presented, facial filler injection–related visual complications have poor prognosis, with approximately 90% of all patients who have suffered OAO or CRAO from facial filler injection ending up with vision of NLP.8Park S.W. Woo S.J. Park K.H. et al.Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections.Am J Ophthalmol. 2012; 154: 653-662Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar Visual recovery is also extremely limited in BRAOs and reported in only 1 case of CRAO. Many management options with the goal of dislodging the emboli and re-establishing the vascular flow have been mentioned in the literature, such as intraocular pressure–lowering medications, anterior chamber paracentesis, ocular massage, medical thrombolysis, hyperbaric oxygen, hemodilution, among others.7Carruthers J.D. Fagien S. Rohrich R.J. Weinkle S. Carruthers A. Blindness caused by cosmetic filler injection: a review of cause and therapy.Plast Reconstr Surg. 2014; 134: 1197-1201Crossref PubMed Scopus (178) Google Scholar, 20Ozturk C.N. Li Y. Tung R. et al.Complications following injection of soft-tissue fillers.Aesthet Surg J. 2013; 33: 862-877Crossref PubMed Scopus (161) Google Scholar To date, no management has proved effective, and no consensus exists on the proper management of injection–related vision loss.Given the frequent use of periocular injections and the increasing popularity of facial filler injections, it is crucial to raise physician awareness about the anatomical concerns that may lead to this potentially blinding complication. There is also a need to discuss the potential risk for vision loss with patients who are considering periorbital or facial injections, or both, especially for injection over higher-risk regions such as glabella and nasolabial fold and with higher-risk materials such as autologous fat and hyaluronic acid. Facial and periorbital regions are rich in vascular supply given the extensive internal-external carotid branching and anastomoses.1Tansatit T. Moon H.J. Apinuntrum P. Phetudom T. Verification of embolic channel causing blindness following filler injection.Aesthetic Plast Surg. 2015; 39: 154-161Crossref PubMed Scopus (35) Google Scholar As a result, any foreign material introduced (either accidentally or iatrogenically) around the eye and facial region has the potential of introducing emboli into the ophthalmic circulation, which could lead to devastating consequences. Severe and often permanent vision loss after injections in the facial areas is a rare, but known complication that has been reported within nasolabial folds, glabella, intranasal, periocular, and forehead regions.2Park S.H. Sun H.J. Choi K.S. Sudden unilateral visual loss after autologous fat injection into the nasolabial fold.Clin Ophthalmol. 2008; 2: 679-683PubMed Google Scholar, 3Lee C.M. Hong I.H. Park S.P. Ophthalmic artery obstruction and cerebral infarction following periocular injection of autologous fat.Korean J Ophthalmol. 2011; 25: 358-361Crossref PubMed Scopus (46) Google Scholar, 4Dreizen N.G. Framm L. Sudden unilateral visual loss after autologous fat injection into the glabellararea.Am J Ophthalmol. 1989; 107: 85-87Abstract Full Text PDF PubMed Scopus (139) Google Scholar, 5Carle M.V. Roe R. Novack R. et al.Cosmetic facial fillers and severe vision loss.JAMA Ophthalmol. 2014; 132: 637-639Crossref PubMed Scopus (4) Google Scholar, 6Carle M.V. Roe R. Novack R. Boyer D.S. Cosmetic facial fillers and severe vision loss.JAMA Ophthalmol. 2014; 132: 637-639Crossref PubMed Scopus (77) Google Scholar, 7Carruthers J.D. Fagien S. Rohrich R.J. Weinkle S. Carruthers A. Blindness caused by cosmetic filler injection: a review of cause and therapy.Plast Reconstr Surg. 2014; 134: 1197-1201Crossref PubMed Scopus (178) Google Scholar, 8Park S.W. Woo S.J. Park K.H. et al.Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections.Am J Ophthalmol. 2012; 154: 653-662Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar We review the current literature on the topic of visual and vascular compromise caused by facial and periorbital injections, as well as present a case of transient vision loss to no light perception (NLP) after subtenon triamcinolone acetonide (Kenalog; Bristol-Myers Squibb) injection because of ophthalmic artery occlusion (OAO) with full visual recovery. A 77-year-old female with persistent bilateral cystoid macular edema (CME) after cataract surgery refractory to topical corticosteroid and nonsteroidal anti-inflammatory drug was referred for subtenon Kenalog injection. The patient received 2 uneventful subtenon Kenalog injections bilaterally because of the persistent CME. On her third visit for subtenon Kenalog injection, 15 seconds after injection of the right eye over the superotemporal quadrant, the patient suffered vision loss from 20/80 to NLP with associated nausea and right orbital pain. Immediate anterior segment examination was unremarkable other than localized tenderness and fullness over the lacrimal gland (Fig. 1A). Posterior segment examination demonstrated deep white lesions within the choroidal vasculature, as well as white crystal-like lesions within small terminal retinal arterioles (Fig. 2). There were no signs of central retinal artery occlusion (CRAO), but retinal perfusion was occludable with moderate digital pressure. Intravenous Fluorescein Angiography (IVFA) demonstrated small peripheral ischemic areas, but there was no filling defect. Urgent magnetic resonance scan of the orbits performed 2 hours after injection showed enlargement of the right medial rectus muscle and the lacrimal gland, without other orbital abnormalities (Fig. 1B). Repeat examination after the magnetic resonance imaging, approximately 4 hours later, showed the patient had experienced a steady vision improvement after injection back to the 20/80 level. At 1-week follow-up, vision improved to 20/50 with dramatic resolution of her CME on optical coherence tomography. Fundus examination demonstrated complete resolution of the white crystal-like lesions within the retinal arteries and choroidal vasculature. At 1-month follow-up, patient’s best corrected visual acuity improved to 20/40 without any residual signs of CME. Posterior subtenon injection of corticosteroid was first described by Nozik in 1972 for the treatment of uveitis.9Nozik R.A. Periocular injection of steroids.Trans Am Acad Ophthalmol Otolaryngol. 1972; 76: 695-795PubMed Google Scholar Since then, subtenon Kenalog injection has been used extensively among ophthalmologists as an effective method for controlling uveitis refractory to topical medications. Although subtenon injection of Kenalog has been generally considered safe, numerous complications have been reported, such as soft tissue swelling, cataract formation, increased intraocular pressure, pseudoptosis, accidental injection into the subretinal space and globe penetration, retrobulbar hemorrhage, and retinal and choroidal vascular occlusion.10Modarres M. Parvaresh M.M. Peyman G.A. Accidental subretinal injection of triamcinolone acetonide.Ophthalmic Surg Lasers. 1998; 29: 935-938PubMed Google Scholar, 11Moshfeghi D.M. Lowder C.Y. Roth D.B. Kaiser P.K. Retinal and choroidal vascular occlusion after posterior sub-Tenon triamcinolone injection.Am J Ophthalmol. 2002; 134: 132-134Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 12Doshi A. Gariano R.F. Visual loss associated with accidental subretinal injection of triamcinolone acetonide.Retin Cases Brief Rep. 2008; 2: 160-162Crossref PubMed Google Scholar Among these, vascular occlusion is considered the most serious and has been associated with permanent and irreversible visual loss. In our case, we propose that the vision loss was due to vascular compromise from Kenalog being accidentally injected into the lacrimal artery and travelling retrogradely into the ophthalmic artery, resulting in transient OAO. The enlargement seen in the lateral rectus muscle and lacrimal gland was likely due to local accumulation of Kenalog and vascular congestion of the lacrimal artery. Luckily, there was no permanent vision loss as the OAO from Kenalog suspension was transient. The Kenalog preparation is made of a suspension free of large particles/emboli that could result in permanent or prolonged occlusion. After the injection pressure dissipates, the Kenalog suspension could disperse and flow into distal smaller vessels under the arterial pressure, thereby relieving and recanalizing the transient vascular obstruction but travelling to more distal branches of the ophthalmic artery, resulting in clinically visible deposits within the choroid via the short posterior ciliary arteries and the retina through the central retinal artery. As the blood flow is re-established within the ophthalmic artery and central retina artery, the vision recovered spontaneously and the CME resolved quickly with the high concentration of intravascular Kenalog. To our knowledge, this is the first case in the literature of transient OAO with full and spontaneous visual recovery. Also, it is important to note that the manufacturer has specifically recommended against the use of intraturbinal, periocular, and intraocular Kenalog injections because of the lack of safety studies and risk for blindness.13KENALOG®-10 (triamcinolone acetonide) prescribing information. Princeton, NJ: Bristol-Myers Squibb Company. Available from: packageinserts.bms.com/pi/pi_kenalog-10.pdfGoogle Scholar Indeed, vision loss caused by vascular compromise after intranasal, forehead, and eyelid Kenalog injection has been well documented in the literature.14Moss W.J. Kjos K.B. Karnezis T.T. Lebovits M.J. Intranasal steroid injections and blindness: our personal experience and a review of the past 60 years.Laryngoscope. 2015; 125: 796-800Crossref PubMed Scopus (17) Google Scholar, 15Edwards A.O. Central retinal artery occlusion following forehead injection with a corticosteroid suspension.Pediatr Dermatol. 2008; 25: 460-461Crossref PubMed Scopus (18) Google Scholar, 16Liu O.G. Chunming L. Juanjuan W. Xiaoyan X. Central retinal artery occlusion and cerebral infarction following forehead injection with a corticosteroid suspension for vitiligo.Indian J Dermatol Venereol Leprol. 2014; 80: 177-179Crossref PubMed Scopus (16) Google Scholar, 17Yağci A. Palamar M. Eğrilmez S. Sahbazov C. Ozbek S.S. Anterior segment ischemia and retinochoroidal vascular occlusion after intralesional steroid injection.Ophthal Plast Reconstr Surg. 2008; 24: 55-57Crossref PubMed Scopus (23) Google Scholar, 18Martin P.A. Church C.A. Petti Jr, G.H. Hedayi R. Visual loss after intraturbinate steroid injection.Otolaryngol Head Neck Surg. 2003; 128: 280-281Crossref PubMed Scopus (11) Google Scholar Therefore, it is critical for physicians to document and have thorough discussions about all the potential risks associated with facial and periocular injections as part of the informed consent process. In addition to periocular Kenalog injections, facial filler injections for cosmetic wrinkle removal and facial augmentation have also been reported to have severe visual-threatening complications secondary to vascular occlusion. It is important for ophthalmologists to be aware of the potential visual complications of facial filler injections because of their rising popularity for cosmetic purposes. Currently, facial filler injection is the second most commonly performed minor procedure by plastic surgeons and dermatologists after botulinum toxin injections.19American Society for Aesthetic Plastic Surgery. New York: ASAPS National Cosmetic Surgery Databank Statistics 2012. Available from: www.surgery.org/sites/default/files/ASAPS-2012-Stats.pdfGoogle Scholar, 20Ozturk C.N. Li Y. Tung R. et al.Complications following injection of soft-tissue fillers.Aesthet Surg J. 2013; 33: 862-877Crossref PubMed Scopus (161) Google Scholar Vision loss presents as an immediate complication of facial filler injection with other associated signs and symptoms depending on the location of vascular occlusion.7Carruthers J.D. Fagien S. Rohrich R.J. Weinkle S. Carruthers A. Blindness caused by cosmetic filler injection: a review of cause and therapy.Plast Reconstr Surg. 2014; 134: 1197-1201Crossref PubMed Scopus (178) Google Scholar, 8Park S.W. Woo S.J. Park K.H. et al.Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections.Am J Ophthalmol. 2012; 154: 653-662Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar OAO, CRAO, and branch retinal artery occlusion (BRAO) after filler injections have all been reported. OAO and CRAO have been associated with the worst visual prognosis. Given the important vascular supply from branches of ophthalmic artery, OAO is commonly associated with pain, pupillary abnormalities, ophthalmoplegia, ptosis, decreased choroidal thickness, and absence of cherry red spot.8Park S.W. Woo S.J. Park K.H. et al.Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections.Am J Ophthalmol. 2012; 154: 653-662Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar The mechanism of vascular compromise from facial filler injections is thought to be due to retrograde injection of filler materials through distal arterioles under high injection pressure.7Carruthers J.D. Fagien S. Rohrich R.J. Weinkle S. Carruthers A. Blindness caused by cosmetic filler injection: a review of cause and therapy.Plast Reconstr Surg. 2014; 134: 1197-1201Crossref PubMed Scopus (178) Google Scholar, 8Park S.W. Woo S.J. Park K.H. et al.Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections.Am J Ophthalmol. 2012; 154: 653-662Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar Once the injection pressure has been removed, the filler materials travel distally and result in vascular occlusion depending on the filler particle size and the diameter of affected arteries. Many filler materials are available, differing by particle sizes and duration of effect. Fillers made of autologous fat, hyaluronic acid, collagen, and polymethyl methacrylate have been reported with visual complications. Of these, autologous fat and hyaluronic acid have been reported to account for the vast majority of filler-related vision loss reported in the literature, with autologous fat being responsible for approximately 50% of all cases. Autologous fat has also been established as the most likely filler material to cause OAO. The high risk associated with autologous fat and hyaluronic acid is likely due to their large particle size with hyaluronic acid particles measuring 400 μm in diameter and autologous fat composed of even larger and variable-sized fat globules.21Gold M.H. Use of hyaluronic acid fillers for the treatment of the aging face.Clin Interv Aging. 2007; 2: 369-376PubMed Google Scholar Given the 2-mm diameter of the ophthalmic artery and 160-μm diameter of the central retinal artery, it is understandable why autologous fat results in more OAO, whereas hyaluronic acid filler is more likely to result in CRAO. The site of facial filler injections is also a factor in the risk for visual complications with filler injections. Among all published reports, injections over glabella, nasolabial folds, and forehead regions are associated with the greatest risk. The risk for vascular compromise at each site is likely determined by the underlying vascular anastomoses and proximity to the ophthalmic artery. For instance, retrograde travel of emboli from the glabellar region likely comes from the supratrochlear or supraorbital artery, whereas dorsal nasal, angular, and/or lateral nasal arteries likely account for emboli travel of injections over the nasolabial folds. Contrasted with the complete visual recovery from transient OAO seen with Kenalog injection in the case presented, facial filler injection–related visual complications have poor prognosis, with approximately 90% of all patients who have suffered OAO or CRAO from facial filler injection ending up with vision of NLP.8Park S.W. Woo S.J. Park K.H. et al.Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections.Am J Ophthalmol. 2012; 154: 653-662Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar Visual recovery is also extremely limited in BRAOs and reported in only 1 case of CRAO. Many management options with the goal of dislodging the emboli and re-establishing the vascular flow have been mentioned in the literature, such as intraocular pressure–lowering medications, anterior chamber paracentesis, ocular massage, medical thrombolysis, hyperbaric oxygen, hemodilution, among others.7Carruthers J.D. Fagien S. Rohrich R.J. Weinkle S. Carruthers A. Blindness caused by cosmetic filler injection: a review of cause and therapy.Plast Reconstr Surg. 2014; 134: 1197-1201Crossref PubMed Scopus (178) Google Scholar, 20Ozturk C.N. Li Y. Tung R. et al.Complications following injection of soft-tissue fillers.Aesthet Surg J. 2013; 33: 862-877Crossref PubMed Scopus (161) Google Scholar To date, no management has proved effective, and no consensus exists on the proper management of injection–related vision loss. Given the frequent use of periocular injections and the increasing popularity of facial filler injections, it is crucial to raise physician awareness about the anatomical concerns that may lead to this potentially blinding complication. There is also a need to discuss the potential risk for vision loss with patients who are considering periorbital or facial injections, or both, especially for injection over higher-risk regions such as glabella and nasolabial fold and with higher-risk materials such as autologous fat and hyaluronic acid.